Seeking Simplicity in Healthcare

Today I spent my lunch hour listening to a webinar on the highlights of what physicians need to know to be ready for MACRA (Medicare Access and CHIP Reauthorization Act) implementation, specifically new CMS regulations for the Quality Payment Program (QPP) that physicians accepting Medicare must participate in starting in 2017 in order to not suffer financial penalties. Despite the rather convoluted alphabet soup of acronyms and new regulations, I’ve heard this topic presented by multiple sources over the past few months and am starting to feel I have a fairly good grasp on the content, possibly even well enough to present it to a colleague if necessary. Most would consider this going above-and-beyond for me, if not completely unnecessary, given that I am still completing my residency and working in an environment where I don’t personally have to pay much attention to billing and quality metrics as someone else is doing that part of the job and my not knowing wouldn’t affect my salary or really how I interact with patients one bit.

The problem is, I won’t be in this environment forever. In less than a year and a half, I will graduate and move on into the world where I can prioritize my professional autonomy and would very much like to have my own practice. Unfortunately, to do this requires a tremendous amount of knowledge beyond what has been taught in any of my formal education to become a physician. So sacrificing a peaceful lunch hour to further school myself on the ins-and-outs of avoiding reduced payment for Medicare patients due to my own inadequate reporting is part of the burden I must bear. Unless… I choose to practice differently and refuse to participate entirely.

This whole situation causes me to reflect on a particular moment of reckoning I had back in May 2016. I was giving a presentation at a local elementary school to a group of parents to explain how the state of California had recently expanded Medicaid eligibility to all minors under the age of 19, regardless of immigration status, and how to ensure their children would be properly and promptly enrolled. As is usually the case whenever a physician opens herself up to a broader audience like this, I started getting a lot of questions from those present about their personal family situations. Though rather than focusing on the children which was the initial intent of the presentation, it was regarding themselves or other adult family members who were unable to access our inadequate patchwork of services open to undocumented immigrant adults. I take great pride in understanding the complex interworkings of government programs and have made considerable effort to keep abreast of new developments, something I was doing long before even starting medical school. I happily serve as a reference point for my peers and patients alike. But as I was fielding what seemed like an endless stream of questions that night and watching the defeated looks on the faces of these parents who were clearly overwhelmed by the many steps, entry points, applications, and exceptions to the various programs I was describing for their individual situations, I finally realized just how absolutely crazy this all is.

What good is it for me to be an expert at the ins and outs of the dozen different programs and services, each with their own applications, billing, and reporting requirements, if the systems we’ve created are so completely convoluted that my patients can’t even begin to access them? It was at that moment that I knew for certain that I would need to find a way to practice differently, in a manner that anyone could understand and all could access.

Direct primary care is a beacon of hope in the insurance and billing madness. This model of care is conducted by physicians who rather than billing on a per-visit basis, instead charge a flat monthly rate to receive service at their practice and forego billing insurance entirely. For the physician, this substantially lowers overhead and administrative costs of the practice, providing them with a fixed income stream and allowing more time to participate in actual patient care. Most physicians currently practicing under this model are able to offer visits from 30 minutes to an hour in length (versus the 10 to 15 minutes typical in most traditional offices), have smaller patient panels, and more easily accommodate patients for same-day sick visits. Without the worry about lack of payment for certain services, these physicians are even able to interact with their patients in whatever way makes the most sense, whether that’s discussing symptoms over the phone or through video chat, or possibly even conducting a home visit where warranted. With easier access and more time to spend with your doctor, is it any wonder that these practices have demonstrated significant improvements in patient health outcomes?

What if I told you that on top of providing better care that these practices are even substantially reducing the cost of care? Consider that a typical single office visit to a primary care physician is billed at upwards of $150, excluding any additional tests or procedures. But many of the practices serving in this model are able to charge a flat rate of just $50 monthly for a typical adult, oftentimes providing further discounts for children or families. Frequently, these practices have also negotiated special pricing with labs and imaging centers to obtain tests much nearer to cost than the rates negotiated with typical insurers and even lists of local specialists who have similarly negotiated flat rate reduced fees for patients who will cash pay for services.

For years now, it has been a Republican talking point to bundle high-deductible health plans with health savings accounts as a solution to get patients to become more savvy consumers when it comes to healthcare. As a self-identifying progressive, as a medical student, I used to rail at the idea. It was completely dismissive of the fact that for low-income patients, there was no way on earth they would ever be able to stash away $10,000 to cover the potential deductible for such a plan. Until I realized that this was happening anyway. For my undocumented patients who are without other resources or methods of funding, they are frequently denied service for non-emergent procedures until they can come up with a down payment, often in this exact price range. Furthermore, even on the sliding scale fee schedules charged by our county clinics and community health centers, just 3 or 4 visits could exceed the cost of membership to a direct primary care practice for an entire year. Not to mention, making the decision to pay $150 or $200 to see a doctor when one is acutely ill is often much harder to stomach or even come up with than a planned monthly fee similar to a cell phone or cable bill. A high functioning primary care physician who is given the ability to dedicate ample time and attention to her patients will find that the need to refer to specialists becomes a rarity rather than the norm, no longer a dumping ground for things I simply don’t have time to address in our 15 minutes together.

The benefits to both physicians and patients of such a plan are undeniable. So why isn’t everyone doing it? Because for many of us, it necessarily forces us to exclude some of our patients. Right now, California state law treats a monthly fee charged for health care as a “health plan,” meaning that the doctors taking part in these models open themselves to legal exposure of potentially being treated like an insurance product even though the fees they are charging are to cover services at that practice alone. Furthermore, government and even privately funded health insurance programs will not cover the monthly fee to practices in this model. Traditional Medicare, our federal insurance for the elderly, specifically prohibits payment for this monthly fee for membership-model practices despite the fact that it has proven to be an effective and successful model for patients served by privately administered Medicare Advantage programs.

My patients need simplicity. They need to understand exactly how much things cost and what, precisely, they are getting for the amount they are paying. Physicians need simplicity as well, not a never ending stream of regulations and reporting requirements that do little to improve care and much to limit our time focusing our attention where it would be better served. Even for a policy nerd like myself, this is getting exhausting, and I recognize that my longevity in practice will depend greatly on my ability to simplify things and create a model where my attention can be focused on the health of my patients rather than my ability to understand the latest initiative of a group of bureaucrats who understand little to nothing about medicine.